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SA.v OAQUIN LOCAL HEALTH DISTRICT <br /> VC OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ,. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-S9Sp <br /> Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San,Joaquin Local Health District for a permit to construct <br /> and/or install the work herein d-,scribed. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /�b CENSUS TRACT <br /> Owner's Name Phone <br /> Address D City <br /> Contractor's Name icense Phone,3<9-3,W-3 <br /> r TYPE OF WORK (Check): NEW WELL J-T DEEPEN /7 RECONDITION /-T DESTRUCTION r f <br /> PUMP INSTALLATION � PUMP REPAIR /� PUMP REPLACEMENT <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ( Industrial Cable Tool Dia. of Well Excavation O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 4 Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> R PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> pUNP P PLACEMENT: State Work Done yogle 1-e adaade <br /> PUMP REPAIR: /-7 State Work Done <br /> JDESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stats of California per to or regulating well construction. Within FIFTEEN DAYS <br /> attar cotaplation of my work on a new well. I will furnish the San Joaquin Local Health Distriot a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> OF DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1-Y FOR <br /> O 1 <br /> APPLICATION •ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II OUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 -A <br /> E H 1426 <br /> �,�..1'..�,YMR M1.[R:.";�i/e1�=+�lww'�'�'W"MtV�:3'-'i.1n�+na'�• �. �lF���4�1� � <br />